OP0209-HPR BRIDGE – A QUALITY IMPROVEMENT PROGRAM IN TEAM-BASED REHABILITATION: RESULTS FROM A MIXED METHODS STUDY
Authors: A. L. Sand-Svartrud, G. Berdal, G. J. Aanerud, M. Azimi, T. N. Dager, C. van den Ende, I. Johansen, H. Lindtvedt Valaas, H. Solveig Dagfinrud, I. Kjeken
Journal: Annals of the Rheumatic Diseases (2022)

Background There is a well-known variability in the quality of rehabilitation provided to patients with rheumatic and musculoskeletal diseases (RMDs). Elements to be improved are a higher standardization of the core content, optimal patient participation in goal setting and continuation of the process in tailored follow-up. More knowledge is needed on critical features for successful delivery of improvement programs in rehabilitation. Objectives To investigate how a team-based quality improvement program was implemented and how it influenced the quality in RMD rehabilitation. Methods This convergent mixed methods study is nested within a stepped-wedge, randomized controlled trial where providers at 8 rehabilitation-centers delivered traditional programs in the control phase (T1), and added the BRIDGE quality improvement program in the intervention phase (T2). The BRIDGE program addressed a dialog-based, multidisciplinary approach to support the patients’ self-management, comprising motivational interviewing, goal setting, plans for rehabilitation, feedback and monitoring of progress, and tailored follow up. Providers answered 19 structure indicators from a quality indicator (QI) set for RMD rehabilitation [1] at T1 and T2, and a program-fidelity checklist with 18 items at T2 (both scored 0-100%, 100=best). Qualitative data was collected in three focus groups (FG) with the BRIDGE providers, and analyzed using reflexive thematic analysis. Integration and discussion of findings from the different data sources are ongoing, in our research group. Results Median summary pass rate for the structure QIs for all centers increased from 53 to 90% between T1 and T2. Program-fidelity was high, with a median summary score of 94% (range 6–100%), but lowest for program-components related to follow-up and communication with external services. Themes developed from the FG interviews reflected that variations in how the program was implemented related to features of the providers and institutions. More specific; the delivery of high-quality rehabilitation depended on the degree to which the providers trained their communication skills, used available tools to support their practice, and grounded their interventions in professional reasons. Critical organisational features at the institutions were dedicated time for team-work based on the patients’ plans for self-management, and sufficient attention to needs for involvement of next of kin or external services. Additionally, better program-implementation occurred if providers experienced an institutional culture for quality improvement, such as educational initiatives from the leaders. Preliminary integration of data is summarized in Figure 1. Congruent evidence in both quantitative and qualitative findings addressed the sustained needs for better quality in the area of follow-up across levels of care. However, the qualitative findings provided expanded insights on variability also in initial parts of the rehabilitation process. Presumably, these variations in delivery reported in interviews are important for the effectiveness of a quality improvement program, but difficult to capture in questionnaires. Figure 1. Complementary viewpoints on how the BRIDGE program was provided and how it influenced the quality of rehabilitation. Conclusion To target specific strategies for quality improvement, we suggest a combined attention not only to recommended care reflected in quality indicators and measurable aspects of fidelity, but also to contextual factors, including the providers’ confidence and skills needed to provide a high-quality delivery of all components in a rehabilitation improvement program. References [1]Johansen et al. A quality indicator set for use in rehabilitation team care of people with rheumatic and musculoskeletal diseases; development and pilot testing. BMC Health Serv Res. 2019;19(1). Disclosure of Interests None declared